Case Study
The Untitled Pizza-Making Simulator for Amblyopia
Transforming amblyopia treatment through a VR experience, training the weaker eye through low-contrast play

Overview
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Amblyopia, often referred to as "lazy eye," is a neurodevelopmental condition where the brain favors one eye over the other, leading to decreased vision in the weaker eye. Traditionally, amblyopia is treated through occlusion therapy, where the stronger eye is patched to force the brain to use the weaker eye. While this method can improve visual acuity, it primarily works by increasing neural activity in the underused visual pathways.
However, patching has significant limitations, including the risk of suppressing function in the stronger eye and discomfort associated with wearing the patch. Many children also find patching socially and emotionally distressing, leading to poor adherence to the treatment regimen.
Solution
Our VR pizza simulator addresses these barriers by creating an engaging and immersive therapeutic environment that encourages the use of the weaker eye without completely occluding the stronger one. By supplementing traditional patching therapy, especially for children who struggle with adherence, this game could transform amblyopia treatment into a more enjoyable and effective experience.
Video trailer of prototype showcased at the MIT Brain and Cognitive Sciences building.
User Research
We first began with the research process for the science behind amblyopia and our approach. To develop an effective and fun treatment for amblyopia, we first dove into the research behind the condition and our approach. We consulted experts in ophthalmology and game design, asking them about the significant challenges children aged 4-8 face with amblyopia treatment. We explored the most effective time periods for treatment and how it fits into a child's daily routine. We also sought insights on strategies and incentives that successfully encourage adherence to treatment protocols.
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Our research revealed that integrating treatment into a child's routine in a way that's engaging and enjoyable is crucial. With this in mind, we designed a VR-based treatment that transforms therapy into a fun adventure. Our goal is to make this game so engaging that children look forward to their two-hour therapy sessions, transforming a tedious task into an enjoyable experience. This way, they get the treatment they need without the usual resistance, making the journey to better vision a fun and exciting one.
We also spoke with Dr. Sinha to discuss our approach to treatment, specifically as it related to choosing what filter to apply. As a vision neuroscientist with expertise in amblyopia, Dr. Sinha explained the neural underpinnings of amblyopia, the effects of the condition on vision, and summarized the literature around what current treatments are available and effective.
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Early prototypes of our filter included patterned filters, binocular vs monocular filters, filters applied to the focal point vs the entire visual field, basic color filters, and filters with different levels of opacity. In learning from Dr. Sinha that the visual processing of spatial frequency and contrast is disrupted in amblyopia, we choose to proceed with a filter that would reduce the contrast of the visual input to the non-amblyopic eye.
The Science of the Treatment
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We also explored ways to improve spatial frequency detection by attempting to apply Gabor patches to game objects. Gabor patches are black and white stripes with an applied Gausian envelope and commonly used in vision neuroscience research, as they induce activity in neural populations involved in low-level vision processing. However, we found that there were technical issues with implementing Gabor patches to game objects, and because the filter had the greatest therapeutic potential, as evidenced by effectiveness of patching, we chose to focus our attention on the filter rather than troubleshooting the application of Gabor patches to game objects.
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As a potential form of treatment specific to the affordances of VR, Dr. Sinha informed our team about research suggesting that audio cues paired with visual stimuli increased measures of visual processing in patients with amblyopia. This provided us with another therapeutic avenue for our game outside of our planned use of a filter.



Before: Three people playing in the same game, but with differing maps, weapons, and rooms making it difficult to communicate in game.

After: Animation showcasing proposed additional feature allowing a pop-up of what each character with a deferring DLC is currently viewing in relation to your items
The Science of Engagement
To figure out what genre of game to create, we researched the most popular games for children. These games consisted of Minecraft, Roblox, most LEGO games, Fortnite, Mario, and The Legend of Zelda: Tears of the Kingdom/Breath of the Wild. For VR games, there was Among Us VR, Job Simulator, Fruit Ninja VR, Gorilla Tag, and Five Nights at Freddy’s: Help Wanted/Help Wanted 2. Common elements in these games are:
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Sandbox/Creative elements
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Physics-based
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Simple narratives or lack thereof
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Player reward systems that had easy, medium, and hard achievements
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Competitive elements (PvP and PvE)
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Large online communities
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We also reached out to James Marcey, a Marblehead Recreation and Parks staff member, to get a sense of how many children between the ages of 4-8 were interested in VR. He polled some of the after school camps and explained to us that out of the groups he polled, 85% of children 4-8 were interested in VR and 100% of children 4-8 owned a headset or knew someone who does. Additionally, James said that children 4-8 enjoyed throwing games, building/stacking games, and manipulating objects in various ways to see how they would react with the environment (physics-based games). These games would last about 20 minutes each due to the children’s attention spans. James’ final words of advice were that children enjoy competition, instant gratification, and working towards bigger achievements.
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Make the above into data visuals
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Before: Players are not aligned with their lists, difficult to see vertical highlight meant to help user hone in on specific player who is currently helping them

After: Players are aligned with their lists, with vertical list highlighted to the same value as the horizontal list, allowing users to more visibly see list of player currently helping them
Gameplay
Upon completion, an end-stage graphic will display the player's grade, level progress, and quest progress. Options to progress to the next level, replay the level, or return to the menu are provided.
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Based on this information, we settled on creating a physics-based pizza-making simulator. The competitive element of making better pizzas than your competitors provides an incentive, which is inspired by Roblox tycoon games. The reward system we designed consists of leveling up through daily and weekly quests has been shown to be highly engaging–especially Fortnite and popular mobile games. Moreover, the game can be easily re-skinned to appeal to different audiences and be culturally relevant to audiences that are not from America.
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We decided to make a tangible goal for this prototype by creating a vertical slice that includes the tutorial of the game. The vertical slice aims to include several key features: a functional contrast filter with settings to toggle between eyes, a start menu with play and settings buttons, and options for adjusting contrast and volume. There will also be a quest board displaying daily and weekly quests to allow children more options to be engaged, a tutorial stage with stations arranged sequentially, and a day screen showing the time of day and level progress. The time of day would correlate with a certain level of difficulty within the game.
The gameplay flow involves taking customer orders from a ticket that appears on a carousel, taking the crust (pre-stretched pizza dough) out of the fridge, applying the sauce, and adding cheese and toppings from salad-bar-style containers. Toppings include items like olives, pepperoni, and pineapple, which are placed on the pizza according to the order ticket. The player then bakes the pizza by placing it in the oven and using a timer UI element. Finally, the player places the pizza in the serving area of their pizza stand to deliver the order to the customer!
User Interface
Mobile games and Mario-like games were significant audio inspirations for the overall audio direction. Bright, poppy audio brings the game to life, creating positive feedback for in-game actions. The music emphasizes the liveliness of the environment, using a fast bpm and syncopated rhythms with Koji-Kondo-like harmony. The sound effects are cartoonish and much like sound effects heard in Roblox and large-scale mobile games.
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When ideating about audio, Dr. Sinha brought up that a lot of children with amblyopia have other conditions that impede their ability to perceive any depth, so we designed an audio system that would enable the user to locate an interactable object. Spatialized audio “sparkles” will help the child pinpoint where the interactable objects are located and as the child reaches towards an object, there is a sound that plays to notify that they have reached far enough to pick the object up.
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For dialogue, we chose a narrator voice that resembled that of an elderly man for a child to feel like they are taking over as the next generation. While AI text-to-speech tools are available, the team ultimately decided to use a TikTok voice filter over a recording of one of us reading the narration script, as the filters available on TikTok were not only free, but easy to implement. Because the filter was applied to one of our own voices, we had more control over more nuanced vocal characteristics, like inflections, sighs, chuckles, etc.
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For our art approach, we used a combination of 2D objects and 3D objects with flat or hand painted textures/materials. The immediate area and interactable items were created as three dimensional objects while non-interactable elements in the distance are flat planes. This approach helps prevent the open environment from becoming too overwhelming and enhances the overall aesthetic of the game by keeping things brightly colored. For the assets, each team member selected their favorite topping to include as player options, providing a fun, personalized touch. Additional easter eggs include a variety of billboards some of which include various appearances of a pigeon wearing a VR headset to keep things silly.
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For our UI, we chose a stylized font (open dyslexic) that would be easier to read for children while also fun and child-like. We chose colors for our UI that were of high contrast to make the design easier for children to view our game. We created pizza tickets which include an image of the topping itself that when implemented would show the player what order is next.
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After creating the environment, we realized that a kitchen is a fairly large area. We didn’t want people to need huge amounts of free space to play our game, so we opted to use ray interactors with our controllers instead of chef hands. The scale is meant to be child-friendly but the ray interactors make it possible to be played by anyone with controllers.
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For our project we used a number of tools. The MetaQuest2 was our intended VR headset. Unity was used in the creation of the game scene and space itself. Figma was used for UI. Wwise was used for audio. An AI voice filter was used in the creation of our narration voice. JIRA was used for our project management and task delegations.
Significance
There are at least three ways our game holds large-scale significance: treatment accessibility, expanding our understanding of amblyopia, and VR as a healthcare tool.
Accessibility of treatment: To reiterate, this project aims to make amblyopia treatment more accessible, particularly from a tolerance standpoint. Traditional treatments, such as eye patching, can be uncomfortable, stigmatizing, and often result in low adherence, especially among children. By leveraging an engaging VR game, this project offers a more enjoyable and less intrusive alternative, increasing the likelihood that patients will complete the treatment and achieve better outcomes.
Contributing to Our Understanding of Amblyopia: Through its innovative design, this project has the potential to deepen our understanding of amblyopia and how the brain processes visual information. By incorporating specific contrast and spatial frequency features into the game, we can explore how these visual elements influence neural plasticity and vision restoration. This project may provide valuable data to inform future research and refine therapeutic approaches for amblyopia.
Contribute to the Growing Body of Work Using VR in Healthcare: Virtual reality is an emerging tool in healthcare, and this project adds to the growing body of evidence supporting its efficacy as a therapeutic intervention. By demonstrating how VR can be used to treat amblyopia—a condition with few engaging treatment options—it highlights the versatility and potential of VR in addressing other neurological and visual disorders. This project not only showcases VR’s applications in healthcare but also inspires further exploration of its possibilities in therapeutic innovation.
Additionally, for a couple of members from our team, Neil and McKena, this game holds personal significance:
“I’m thrilled that we have a prototype for adapting my childhood treatment for modern technology. I think that this will help people like me who have binocular vision dysfunction (BVD) conditions like amblyopia and strabismus improve their vision during a time in our lives where we cannot comprehend the importance of treatment. This work feels incredibly rewarding, and I am working on integrating it into future projects.”
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Neil Small
“As an aspiring researcher interested in developing games and wearable technologies as treatments for neurological conditions, this project has been profoundly significant to me. It exemplified the potential of gamified interventions, provided invaluable experience in designing a treatment-oriented game, and reaffirmed my dedication to pursuing this career path.”
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McKena Geiger
Next Steps
Next steps for our game include adding sparkles to objects that are interactable in order to make it easier to differentiate intractable / non interactable items. We would also implement levels as well as a fully implemented reward system to reinforce play. Our game is currently geared towards children between the ages of 4 - 8 but would work best for children older in the age range. We would like to make a design that would also work best for even younger audiences as they would be the ones likely to receive the most benefits from a game like this.